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Patient Visit
PME - Annual Examination
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PAST OCCUPATIONAL HISTORY
Name of Organization
Trade/Designation
Period of Service- in Years
Past Occupational Illness
1.
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2.
PERSONAL INFORMATION
Identification Mark
Date of Examination
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Marital Status
checked >
MARRIED
checked >
UNMARRIED
No. of children
Whether adopting any method of family planning
checked >
YES
checked >
NO
Addiction
checked >
SMOKING
checked >
TOBACCO
checked >
ALCOHOL
Family History
checked >
ASTHMA
checked >
DIABETES MELLITUS
checked >
TB
checked >
HYPERTENSION
checked >
ANY OTHER DISEASE
Drug Allergy
Any other medication
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